Nursing Elites

1. The nurse is preparing to give a dose of a cephalosporin medication to a patient who has been receiving the antibiotic for 2 weeks. The nurse notes ulcers on the patient’s tongue and buccal mucosa. Which action will the nurse take?

• A. Hold the drug and notify the provider.
• B. Obtain an order to culture the oral lesions.
• C. Gather emergency equipment to prepare for anaphylaxis.
• D. Report a possible superinfection side effect of the cephalosporin.

Correct answer: D

Rationale: The nurse should report a possible superinfection side effect of the cephalosporin to the physician as the patient's symptoms may indicate a superinfection that requires treatment. Holding the drug is not necessary unless directed by the provider. Culturing the lesions is not indicated for this situation. There is no evidence to suggest impending anaphylaxis based on the patient's symptoms.

2. Which of the following is a common cause of chronic obstructive pulmonary disease (COPD)?

• A. Smoking
• B. Asthma
• C. Allergies
• D. Chronic bronchitis

Correct answer: A

Rationale: Smoking is the correct answer as it is a well-established common cause of chronic obstructive pulmonary disease (COPD). Smoking leads to long-term damage to the lungs, contributing to the development of COPD. Choice B, asthma, is not a cause but a separate respiratory condition characterized by airway inflammation and hyperresponsiveness. Allergies, choice C, are not a direct cause of COPD but can exacerbate symptoms in individuals with existing COPD. Chronic bronchitis, choice D, is a type of COPD, not a cause of COPD itself, making it an incorrect choice in this context.

3. An older female client has normal saline infusing at 45 mL/hour. She complains of pain at the insertion site of the IV catheter. There is no redness or edema around the IV site. Which action should the nurse take?

• A. Determine which IV medications have recently been administered.
• B. Explain that without redness or edema, there is no need to re-start the IV.
• C. Consult with the healthcare provider about the best location to start a new IV.
• D. Convert the IV to a saline lock and continue to monitor the site.

Correct answer: D

Rationale: Converting the IV to a saline lock and continuing to monitor the site is the correct action in this scenario. When a client complains of pain at the IV insertion site without redness or edema, it may indicate phlebitis or irritation. Replacing the IV may not be necessary if there are no signs of infection or infiltration. Determining the IV medications administered or consulting with the healthcare provider to start a new IV are not immediate actions required for pain management at the insertion site. Therefore, the most appropriate intervention is to convert the IV to a saline lock and closely observe for any changes or complications.

4. Blood for arterial blood gas determinations is drawn from a client with pneumonia, and testing reveals a pH of 7.45, PCO2 of 30 mm Hg, and HCO3 of 19 mEq/L. The nurse interprets these results as indicative of:

• A. Compensated metabolic acidosis
• B. Compensated respiratory alkalosis
• C. Uncompensated metabolic alkalosis
• D. Uncompensated respiratory acidosis

Correct answer: B

Rationale: The correct answer is 'Compensated respiratory alkalosis.' In this case, the client's pH is within the normal range (7.35-7.45), indicating compensation. The low PCO2 (30 mm Hg) suggests respiratory alkalosis, while the low HCO3 (19 mEq/L) is also consistent with a compensatory response. Therefore, the client has a primary respiratory alkalosis that is being compensated for by metabolic acidosis. Choices A, C, and D are incorrect because they do not fit the pattern of the given blood gas values, which indicate respiratory alkalosis with metabolic compensation.

5. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take?

• A. Document findings and continue to monitor the client.
• B. Contact the provider and recommend a 24-hour urine test.
• C. Review the client’s recent dietary selections.
• D. Perform a capillary artery glucose assessment.

Correct answer: D

Rationale: Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the client’s dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

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